ZIMBABWE COP 2021 Country Operational Plan - Strategic Direction Summary May 2021 - Department ...
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ZIMBABWE
Country Operational Plan
COP 2021
Strategic Direction Summary
May 2021
UNCLASSIFIED
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Table of Contents
1.0 Goal Statement
2.0 Epidemic, Response, and Updates to Program Context
2.1 Summary statistics, disease burden, and country profile
2.2 Activities and Areas of Focus for COP 21, Including Focus on Treatment Continuity
2.3 Investment profile
2.4 National sustainability profile update
2.5 Alignment of PEPFAR investments geographically to disease burden
2.6 Stakeholder engagement
3.0 Geographic and population prioritization
4.0 Client-centered Program Activities for Epidemic Control
4.1 Finding the missing, getting them on treatment
4.2 Continuity of Treatment and Ensuring Viral Suppression
4.3 Prevention, specifically detailing programs for priority programming
4.4 Commodities
4.5 Cervical Cancer Programs
4.6 Viral Load and Early Infant Diagnosis Optimization
4.7 Targets for scale-up locations and populations
5.0 Program Support Necessary to Achieve Sustained Epidemic Control
6.0 USG Management, Operations and Staffing Plan to Achieve Stated Goals
Appendix A: SNU Prioritization & Current ART Coverage
Appendix B: Budget Profile and Resource Projections
Appendix C: Minimum Program Requirements
Appendix D: American Rescue Plan Act Activities & Budget
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Acronym List
AE Adverse Event
AGYW Adolescent Girls and Young Women
ANC Antenatal Clinic
ARPA American Rescue Plan Act
ART Antiretroviral Treatment
ARVs Antiretroviral
BMGF Bill & Melinda Gates Foundation
CARGS Community ART Refill Groups
CATS Community Adolescent Treatment Supporters
CBO Community Based Organization
CBS Case-based Surveillance
CCM Country Coordinating Mechanism
CDC Centers for Disease Control and Prevention
CHW Community Health Workers
CLHIV Children Living with HIV
COP Country Operational Plan
CRFs Client Referral Facilitators
CSO Civil Society Organizations
CTX Cotrimoxazole
DBS Dried Blood Spot
DHIS2 District Health Information System Version 2
DoS Department of State
DREAMS Determined, Resilient, AIDS-free, Mentored and Safe
DSD Direct Service Delivery or Differentiated Service Delivery
EHR Electronic Health Records
EID Early Infant Diagnosis
EMR Electronic Medical Record System
eMTCT Elimination of Mother to Child Transmission
ePMS Electronic Patient Monitoring System
FARG Family ART Refill Group
FAST Funding Allocation to Strategy Tool
FBO Faith-Based Organization
FSW Female Sex Workers
GBV Gender Based Violence
GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria
GoZ Government of Zimbabwe
HCD Human Centered Design
HCW Health Care Workers
HDP Health Development Partners
HEI HIV Exposed Infant
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HIV Human Immunodeficiency Virus
HIVST HIV Self-Testing
HMIS Health Management Information System
HR Human Resources
HRH Human Resources for Health
HRIS Human Resource Information System
HSS Health Systems Strengthening
HTS HIV Testing Services
INH Isoniazid (isonicotinylhydrazide drug)
IP Implementing Partner
IPT Isoniazid Preventive Therapy
KP Key Population
KPIF Key Populations Investment Fund
LMIS Logistics Management and Information Systems
LPV/r Lopinavir/ritonavir
LTFU Lost to Follow-Up
M&E Monitoring and Evaluation
MC Male Circumcision
MCH Maternal and Child Health
MMD Multi-Month Dispensing
MMS Multi-Month Scripting
MoHCC Ministry of Health and Child Care
MSM Men who have Sex with Men
NAC National AIDS Council
NATF National AIDS Trust Fund
OI Opportunistic Infections
OVC Orphans and Vulnerable Children
PEP Post-Exposure Prophylaxis
PEPFAR The U.S. President’s Emergency Plan for AIDS Relief
PITC Provider-initiated Testing and Counseling
PLHIV People Living with HIV
PMTCT Prevention of Mother-to-Child Transmission
POART PEPFAR Oversight and Accountability Response Team
POC Point of Care
PrEP Pre-Exposure Prophylaxis
QA/QI Quality Assurance/Quality Improvement
RTK Rapid Test Kit
SCMS Supply Chain Management System
SDS Strategic Direction Summary
SI Strategic Information
SID Sustainability Index and Dashboard
SIMS Site Improvement through Monitoring System
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SNU Sub National Unit
STI Sexually Transmitted Infections
SW Sex Workers
TA Technical Assistance
TAT Technical Assistance for Treatment
TAT Turn Around Time (Laboratory)
TB Tuberculosis
TBD To Be Determined
TG Transgender
TLD Tenofovir Lamivudine Dolutegravir
TLE Tenofovir Lamivudine Efavirenz
TPT TB Preventive Therapy
UNAIDS Joint United Nations Program on HIV/AIDS
UNICEF United Nations Children’s Fund
USAID U.S. Agency for International Development
USG U.S. Government
VACS Violence against Children Survey
VCT Voluntary Counseling and Testing
VHWs Village Healthcare Workers
VL Viral Load
VMMC Voluntary Medical Male Circumcision
WHO World Health Organization
YAZ Young Adult Survey of Zimbabwe
YWSS Young Women Selling Sex
ZDHS Zimbabwe Demographic and Health Survey
ZIMPHIA Zimbabwe Population-Based HIV Impact Assessment
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1.0 Goal Statement
The President’s Emergency Plan for AIDS Relief (PEPFAR) interagency team collaborated with
key partners including the Government of Zimbabwe (GoZ), the Global Fund to Fight AIDS,
Tuberculosis and Malaria (the “Global Fund”), civil society organizations (CSOs), and other
bilateral and multilateral health development partners to develop the 2021 Country Operational
Plan (COP) for FY 2022. The national ART program and other critical HIV service delivery and
prevention programs in Zimbabwe are implemented under the leadership of the Ministry of
Health and Child Care (MoHCC), the Ministry of Primary and Secondary Education (MoPSE) and
the Ministry of Labor and Social Welfare (MoLSW).
COP 2021 aims to advance client centered services and implement resilient programs designed to
mitigate the impacts of COVID-19 on the PEPFAR program. ZIMPHIA 2020 found that 86.8
percent of adults living with HIV were aware of their status and of those aware of their status,
97.0 percent were on antiretroviral treatment. Among those on treatment, 90.3 percent achieved
viral load suppression. These exciting results demonstrate that Zimbabwe has achieved the
second and third 90s nationally. Consequently, PEPFAR must evolve to realign PEPFAR-
supported resources with the current epidemic context (and in the context of COVID-19).
Treatment targets are set to achieve and maintain 100 percent ART coverage within all districts
and across all age and sex bands by the end of FY 2022. PEPFAR Zimbabwe will invest in the
delivery of a comprehensive package of HIV treatment and prevention activities within 44 of
Zimbabwe's 63 districts. To ensure equitable gains towards achieving sustainable epidemic
control across Zimbabwe, the PEPFAR program will also provide above-site technical assistance to
monitor the HIV response in the remaining 19 centrally supported districts. With over 1.1 million
Zimbabweans currently on ART, the PEPFAR program must increase access to viral load
monitoring, while strengthening and expanding efforts to improve retention and viral
suppression, particularly among populations lagging in these areas such as children, young
women, young men, and pregnant women.
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Zimbabwe continues to be challenged with socio-economic issues, fuel shortages, load-shedding,
health worker strikes, and a fragile health care system. Investments in human resources for health
(HRH) have been essential in securing a more stable health care cadre in Zimbabwe. While HRH
and health infrastructure are primarily funded by the MoHCC, PEPFAR has successfully leveraged
and supplements this capacity with key commodities, site-level mentoring, and additional HRH
support for HIV clinical services.
Lastly, PEPFAR continues to work closely with the Global Fund's Country Coordinating
Mechanism (CCM) to ensure the alignment of programming as GF's current funding cycle (2021-
2023). PEPFAR, and the USG more broadly, continues to collaborate with the CCM to harmonize
investments in COVID-19 mitigation measures.
2.0 Epidemic, Response, and Program Context
2.1 Summary statistics, disease burden and country profile
Zimbabwe has a generalized HIV epidemic and is home to 1.27 million people living with HIV
(PLHIV), including 1.19 million adults and 69,972 children. An estimated 1.27 million people were
living with HIV in 2020, with 5.53 being children 0-14 years. Among adults 15+ years living with
HIV, 60.6% were females. Annual all-cause deaths among PLHIV have declined over the past
decade with approximately 28,201 all cause deaths among PLHIV in 2020 compared to 127,871 in
the year 2003. Total new HIV infections declined nationally from 98,668 in 2003 to 24,524 in 2020.
By the end of 2020, ART coverage among all HIV positive adults was 92% for adult men and 93%
for adult women. Coverage for children was slightly lower at 66%.
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The 2020 ZIMPHIA showed that overall HIV prevalence for adults aged 15-49 was 11.8% in 2020,
down from 18.1% in 2005 in the ZDHS. Among persons aged 15 to 64 years, HIV prevalence in the
2020 ZIMPHIA varied geographically, with higher prevalence in the provinces of Matabeleland
North (14.9%), Bulawayo (14.0%), and Matabeleland South (17.6%) than in the other seven
provinces, which were all below 14%. The highest HIV prevalence estimated was nearly 30% for
both males (30.9%) and females (33.3%) but occurred at a slightly older age (50-54 years) among
males as compared to females (45-49 years). The disparity in HIV prevalence by sex was most
pronounced among young persons: HIV prevalence was three times higher among females (6.4%)
than males (2.8%) aged 20 to 24 years.
In terms of viral load suppression (VLS), the ZIMPHIA 2020 showed that among adults living with
HIV (ages 15 years and older) in Zimbabwe, VLS ranged from 66.2% among women aged 15-24
years to 90.3% among women aged 45-54 years, and from 49.2% among men aged 15-24 years to
91.7% among men aged 65 years and older. VLS was higher among women than men at ages 25-34
years, with 70.7% of women and 52.4% of men achieving VLS. Among both sexes, there was a
substantial increase in VLS among men and women aged 35-44 years compared to those aged 15-
24 years and aged 25-34 years. There was also a marked increase in VLS among women aged 45-54
years compared to women aged 35-44 years. Zimbabwe has now met the second and third 90-90-
90 targets and has achieved the overall target for 2020 by exceeding 73% of VLS among all adults
living with HIV.
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UNCLASSIFIEDStandard Table 2.1.1: Host Country Epidemiological Data Profile
Table 2.1.1 Host Country Epidemiological Data Profile12
Standard Table 2.1.2: 95-95-95 cascade: HIV diagnosis, treatment, and viral suppression
Table 2.1.2 95-95-95 cascade: HIV diagnosis, treatment, and viral suppression
HIV Testing and Linkage to ART Within
Epidemiologic Data HIV Treatment and Viral Suppression
the Last Year (PEPFAR FY19 MER Data)
Total
Population HIV Estimated PLHIV ART Viral Tested for Diagnosed Initiated on
On ART
Size Prevalence Total PLHIV Diagnosed Coverage Suppression HIV HIV Positive ART
(#)
Estimate (%) (#) (#) (%) (%) (#) (#) (#)
(#)
Total
16,219,401 7.8% 1,270,056 1,165,985 1,156,780 91% 89% 1,439,295 81,147 76,371
population
Population
6,561827 1.16% 75,796 50,105 49,863 66% 72% 149,198 2,881 2,75213
Figure 2.1.3 National and PEPFAR Trend for Individuals currently on Treatment
Figure 2.1.4 Trend of New Infections and All-Cause Mortality Among PLHIV
UNCLASSIFIED14
Figure 2.1.5 Progress retaining individuals in lifelong ART in FY20.
Figure 2.1.6 Number of clients lost from ART 2019 Q4 to 2020 Q4
UNCLASSIFIED15
Figure 2.1.7 Epidemiologic Trends and Program Response
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000
0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
PLHIV On ART Remaining in Need of ART
UNCLASSIFIED16
2.2 Activities and Areas of Focus for COP 21, Including Focus on Treatment Continuity
As the country achieves epidemic control, the program will focus on ensuring continuity of care
and treatment and keeping clients on treatment healthy using the interventions and activities
illustrated in the figures below.
UNCLASSIFIED17
UNCLASSIFIED18
2.3 Investment Profile
Although Zimbabwe’s national budget allocation to health has modestly increased in recent years
from 6.5% in 2015 to the current 7.6%, it still falls far below the Abuja requirement of 15% and the
actual amounts disbursed often fall below the budgeted levels. Furthermore, the GoZ budget is
mostly for salaries (70%) according to the 2017 Resource Mapping report. This leaves the larger
burden of health system functionality (e.g., commodity needs and distribution, laboratory sample
transportation, and health facility operational costs, etc.) in the hands of external funding donors.
Despite support from Zimbabwe’s health development partners, the consolidated total funding
still falls short of projected requirements to fully implement the national health strategy.
Zimbabwe continues to face an economic downturn and high inflation, a plight which has been
exacerbated even further by the COVID-19 epidemic. The GoZ has established an AIDS levy that
collects millions of dollars each year to procure ARVs and to support other activities. However,
the real value of these funds has declined as the exchange rate has fallen and it is unclear how
much the levy is currently contributing to the response.
UNCLASSIFIED19
Standard Table 2.3.1: Annual Investment Profile by Program Area
UNCLASSIFIED20
Standard Table 2.3.2: Annual Procurement Profile for Key Commodities
Standard Table 2.3.3: Annual USG Non-PEPFAR Funded Investments and Integration
Table 2.3.3 Annual USG Non-PEPFAR Funded Investments and Integration
Non-PEPFAR
Total USG PEPFAR COP
Funding Resources # Co-Funded
Non-PEPFAR Co-Funding Objectives
Source Co-Funding IMs
Resources Contribution
PEPFAR IMs
• Increase utilization of quality family
planning, maternal. neonatal, and child
health services
USAID MCH $3,000,000 N/A N/A N/A • Improve nutrition and water, sanitation,
and hygiene practices.
• Strengthen health system to enable
sustainability
• Prevent TB transmission and renew efforts
to find the missing TB cases.
• Strengthen the capacity of national TB
programs.
USAID TB $6,000,000 N/A N/A N/A • Build country capacity to use existing
resources and to turn evidence into policy.
• Expand the development of new TB
diagnostics, drugs, and vaccines
USAID Malaria $14,000,000 N/A N/A N/A • Reduce malaria-related mortality by 70%
• Increase access to modern family planning
information and contraceptives to
Family Planning $2,000,000 N/A N/A N/A improve maternal and child health
outcomes.
Total $25,000,000
UNCLASSIFIED21
2.4 National Sustainability Profile Update
Over the past several years, there has been significant progress in the expansion of ART initiation.
However, major challenges to achieving high ART coverage and sustainable epidemic control
continue to exist. These include insufficient funding for ARVs and lab commodities, human
resources shortages, continued economic instability, weakening infrastructure, a deteriorating
health system, and heavy reliance on donor funding. The Global Fund and PEPFAR currently
finance the purchase of test kits, condoms, most laboratory services, most human resources at
both central and site levels, and a significant portion of the efforts to strengthen the supply chain
and logistics system.
The PEPFAR team will continue to coordinate closely with the Global Fund, as well as other
donors such as the Bill & Melinda Gates Foundation (BMGF) and the Clinton Health Access
Initiative (CHAI), to ensure that investments are complementary. In the short-to-medium term,
PEPFAR and the Global Fund will continue to support both targeted human resources and
strengthening of the overall health system. Over time, direct support for human resources will be
drawn down strategically as the MoHCC’s capacity and the overall economic situation improves.
During COP 2021, PEPFAR implementing partners will complete the PEPFAR HRH inventory so
that PEPFAR and the GOZ can document more granular details on PEPFAR’s HRH support.
Further, PEPFAR will intensify discussions with the MoHCC and GF to discuss HIV HRH
investments, cadres, and levels of site support needed to sustain the HIV program to help inform
the development of a potential transition plan. PEPFAR will also continue engagement with the
national health development partners working group on the national HRH crisis.
As sustainable epidemic control is achieved and evolves beyond 2020, PEPFAR support will evolve
to respond to the new needs of managing HIV as a chronic condition. This will require policy and
cultural shifts within the HIV sector specifically, and the health system in general. To achieve this,
PEPFAR will continue to support and strengthen health information systems. Support to
indigenous partners will also continue to increase as PEPFAR shifts funding from international
organizations to local community and faith- Sustainability Analysis for Epidemic Control: Zimbabwe
based organizations. Epidemic Type: Generalized
Income Level: Lower middle income
PEPFAR Categorization: Long-term Strategy
Sustainability Strengths: The 2021 SID will PEPFAR COP 19 Planning Level: 162,947,750
be completed in late 2021. The sustainability 2015 (SID 2.0) 2017 (SID 3.0) 2019 2021
Governance, Leadership, and Accountability
profile included here is from SID 2019. 1. Planning and Coordination 9.33 10.00 8.57
Sustainability strengths identified as part of 2. Policies and Governance 7.16 7.11 5.82
SUSTAINABILITY DOMAINS and ELEMENTS
3. Civil Society Engagement 6.17 6.46 3.00
SID 2019 include the following: 4. Private Sector Engagement 2.71 5.92 5.92
5. Public Access to Information 8.00 5.00 5.67
National Health System and Service Delivery
• Planning and coordination (Element 1, 6. Service Delivery 7.22 6.85 6.75
7. Human Resources for Health 8.42 8.40 7.76
Score 8.57): The MoHCC develops and 8. Commodity Security and Supply Chain 6.14 6.14 4.81
9. Quality Management 8.67 8.67 9.33
implements a costed multiyear national 10. Laboratory 4.72 5.50 6.89
strategy and serves as the convener of a Strategic Financing and Market Openness
11. Domestic Resource Mobilization 3.06 7.06 7.58
coordinated HIV/AIDS response. 12. Technical and Allocative Efficiencies 6.70 8.56 8.56
13. Market Openness N/A N/A 6.88
Policies, guidelines, and SOPs exist Strategic Information
14. Epidemiological and Health Data 3.87 4.51 5.18
within the national response, but 15. Financial/Expenditure Data 7.08 10.00 10.00
require greater oversight and stronger 16. Performance Data
17. Data for Decision-Making Ecosystem N/A
7.34
N/A
7.12 7.56
5.00
implementation.
• Quality management (Element 9, Score 9.33): Stakeholders consulted cited strong
institutionalized quality management systems, plans, workforce capacities, and other key
UNCLASSIFIED22
inputs to ensure that quality improvement methodologies are applied to managing and
providing HIV/AIDS services. HIV program performance measurement data are
systematically collected and analyzed to identify areas of patient care and services that can
be continuously improved.
• Technical and allocative efficiencies (Element 12, Score 8.56): There is a demonstrated
commitment among stakeholders to use relevant HIV/AIDS epidemiological, health, and
economic data to inform HIV/AIDS investment decisions.
• Financial/expenditure data (Element 15, Score 10.0): The government remains committed to
collect, track, and analyze available financial data related to HIV/AIDS, including the
financing and spending on HIV/AIDS expenditures.
Sustainability Vulnerabilities: Sustainability vulnerabilities identified as part of SID 2019
include the following:
• Commodity Security and Supply Chain (Element 8, Score 4.81): The GoZ has established a
successful AIDS levy to procure ARVs and support other program activities. However, the
value of these funds has declined over the past two years as inflation has risen and the
procurement of ARVs, HIV rapid test kits, and condoms is heavily dependent on donor
funding. National contributions to supply chain financing are largely limited to health
workforce and infrastructure. Multiple stakeholders and members from diverse CSOs
expressed concern regarding a “weaknesses in the supply chain”. This concern was not
regarding a reliance or dependence on donors for commodity procurement. Stakeholders
were concerned about NatPharm mismanagement and poor performance when it came to
the delivery of commodities to facilities.
• Civil Society Engagement (Element 3, Score 3.00): Stakeholders consulted cited concerns
regarding civil society engagement. Laws exist that indirectly restrict civil society from
playing an oversight role in the HIV/AIDS response. There are opportunities for civil society
groups to engage and provide feedback on HIV/AIDS policies and programs, however, this
input is solicited in an ad hoc manner. Minimal funding (under 9%) for HIV/AIDS related
civil society organizations comes from domestic sources and there are currently no laws and
policies in place which provide for CSOs to receive funding from a government budget for
HIV services through open competition.
2.5 Alignment of PEPFAR investments geographically to disease burden
PEPFAR Zimbabwe continues to evaluate and redirect financial investments towards districts,
communities, and sites with the greatest PLHIV burden and highest treatment gap (i.e., unmet
need) for case-finding. Resources in high volume facilities are being prioritized for TPT scale-up,
cervical cancer screening and treatment, viral load access and coverage, and treatment literacy to
ensure that clients initiated on ART remain virally suppressed. Conversely, in districts with
smaller ART gaps, testing and case-finding efforts will continue to be increasingly targeted, as
resources shift towards adherence, retention, and long-term viral suppression.
UNCLASSIFIED23
Figure 2.5.1. 2020 Annual Viral load coverage by SNU
2.6 Stakeholder Engagement
1. Host country government
The PEPFAR Coordination Office held bilateral meetings with the MoHCC HIV/AIDS
and TB unit to discuss the COP 2021 road map and the need for continued ministry
leadership throughout the COP planning process. Subsequently, numerous MoHCC
representatives attended the weeklong PEPFAR retreat in late January 2021. MoHCC
counterparts deliberated on their specific program areas and contributed to
synchronizing MoHCC priorities with PEPFAR’s. Three MoHCC representatives,
including the Director of the AIDS and TB unit participated in the virtual planning
meeting on April 26 and 27, 2021.
2. Global Fund and other external donors
The Global Fund Portfolio Manager and the local Principal Recipient, UNDP, attended
the PEPFAR retreat and the virtual planning meeting. PEPFAR continues to work closely
with the Global Fund's Country Coordinating Mechanism (CCM) to ensure the alignment
of programming as GF's current funding cycle (2021-2023). PEPFAR, and the USG more
broadly, continues to collaborate with the CCM to harmonize investments in COVID-19
mitigation measures. The team has discussed the potential ARV shortage in 2021
considering both GF and PEPFAR’s flat lined or reduced budgets for the cost area.
Possible funding flexibility to support emerging COP21 program requirements would be
achieved through reprogramming of savings within the HIV grant. Several discussions
were held on the harmonization of COVID-19 support funds between GF and PEPFAR.
UNCLASSIFIED24
Discussions continue at the time of the COP submission. UNAIDS, WHO, and BMGF
attended the retreat and the virtual planning meeting.
3. Civil Society/Community:
Engagement with civil society around COP 2021 kicked off in December 2020 when the
PEPFAR Team attended an Advocacy Core Team meeting to describe FY20 performance
and COP21 strategic direction. In January, several representatives from community
services organizations attended the PEPFAR retreat. The civil society organization (CSO)
core group then convened regional consultative meetings across the various geographical
locations of the country to collect feedback from constituents receiving HIV prevention
and treatment services in Zimbabwe. These consultations led to a streamlined list of
community priorities that later culminated in a separate meeting with Ambassador
Nichols and the PEPFAR Team to deliver the 2021 Community COP outlining the
following community priorities:
1. Prevention
1.1 Expand PrEP Program Rollout
1.2 Expand VMMC Uptake
1.3 Roll out Microbicides for AGYW – Dapivirine Ring (DVR)
1.4 Invest in Social Behavior Change Communication (SBCC)
1.5 Fund and expand “Men and Boys Program” and wellness initiatives,
rebrand condoms and strategically distribute them
2. Treatment
2.1 Improve Pediatric HIV Management and provide optimal Pediatric
ART
2.2 Invest in Treatment Literacy: Women, Girls, Men and Boys
2.3 Expand viral load to 85% of all eligible people
2.4 Improve Sample Transportation
3. Consolidate and strengthen the existing Community-Led Monitoring (CLM)
4. Expand Investment in Key Population Programs (Leave No one Behind)
4.1 Invest in KP Specific DSD Models
4.2 Strengthen ICT Design Structure
4.3 People and Young Men Using Drugs
4.4 SGBV and Psycho-social Support for KPs.
5. Fund and increase the numbers of Human Resources for healthcare workers including lab
technicians, CATs, data clerks, counsellors, nurses, and pharmacists among others in
PEPFAR priority districts. Fund a joint Human Resources for Health inventory and
situation and gap analysis of all frontline health care workers in the country funded by
PEPFAR, Global Fund, Government of Zimbabwe, and other private and bilateral donors
in Zimbabwe.
6. TB/HIV/COVID-19
7. Mental Health
8. Advanced HIV Disease
9. Older Adults Living with HIV and Aging with HIV
10. Integration of COVID-19, SRHR, HIV AIDS in PEPFAR Programs for AGYW living with
Disability.
UNCLASSIFIED25
4. Private Sector
The poor economic and investment climate has made engagement with the private
sector challenging in Zimbabwe. While there were no engagement meetings with the
private sector during COP 2021 planning, PEPFAR will explore opportunities in the
coming year for possible inclusion in COP 2022.
3.0 Geographic and Population Prioritization
PEPFAR used 2020 subnational HIV estimates from the UNAIDS NAOMI model and host country
treatment program data to recalibrate the national HIV epidemic and measure progress toward
the UNAIDS fast track 95-95-95 epidemic control targets across all districts. PEPFAR
programming aims to have 100% of PLHIV on ART at the end of FY22. Together with the
Government of Zimbabwe, >95% of PLHIV will be initiated on ART by the end of FY 22.
Table 3.1: Current Status of ART saturation
Table 3.1 Current Status of ART saturation
Total PLHIV/% of
# Current on # of SNU COP20 # of SNU COP21
Prioritization Area all PLHIV for
ART (FY20) (FY21) (FY22)
COP 21
Attained 1,067,394 986,982 44 44
Scale-up Saturation
Scale-up Aggressive
Sustained
Central Support 197,349 176,012 19 19
TOTAL 1,264,743 1,162,994 63 63
4.0 Client Centered Program Activities for Epidemic
Control
4.1 Finding the missing and getting them on treatment.
As Zimbabwe reaches epidemic control, the COP 2021 strategy for case finding will continue to
emphasize the need to employ HIV testing strategies that reduce testing volumes and eliminate
unnecessary testing using the epidemic control and concentrated target population testing
strategies that were developed in COP20.
HIV testing for epidemic control will focus on client centered, safe and ethical index testing
which complies with the WHO HTS principles (5Cs) of ensuring consent, confidentiality,
providing counseling, correct results, and appropriate connection to follow on services.
Additionally, the program will continue to provide standard of care testing for 100% testing
coverage at ANC, STI and TB programs and diagnostic HIV testing under the epidemic control
testing model. Safe and ethical index testing will be supported by implementing
recommendations following Redcap assessment. Regular review of index testing performance will
UNCLASSIFIED26
be done to ensure that the program closes the loop on all listed contacts in a safe and ethical
manner.
HIV testing at community posts, and community intelligence-based models will continue to
constitute a major part of the concentrated target population HIV testing strategy partnered with
HIVST to make the testing even more efficient at identifying the sub-populations that remain
underserved and are at highest risk. Improvements to the KP program through mapping hotspots
and scale up of differentiated HTS services will be done in COP 21. Targeted HIV testing will also
continue to be provided through HIV prevention programming, including DREAMS, OVC, and
PrEP programs.
A continuous monitoring plan in collaboration with MoHCC, CSOs and other stakeholders will be
supported to ensure continuous quality HIV case finding services. Sites will be expected to
monitor and report on acceptance rates of index testing quarterly. KP population programs will
provide index testing coupled with other strategies such as social network HTS. HIV self-testing
will continue to be used in conjunction with the various HTS models to improve testing efficiency
while reaching highest risk groups.
Finally, cased-based surveillance with recency will be used to identify clusters of recent infections
and offer testing to targeted groups in those social and sexual networks. Additionally, the
program will also make use of the latest ZIMPHIA data to fine tune HTS targeting approaches to
reach the sub-populations with the biggest case finding gaps.
Finding men: Generally, men have lower HTS, and ART coverage as compared to women. As the
country reaches and maintains epidemic control, it must continue to close existing gaps in
identifying men, linking them to treatment and ensure long-term viral suppression. Community
posts, which were successfully adapted from the Zambia Circle of Hope model, will be maintained
as a case-finding strategy to test men, and link them to care during COP 21. Additionally, men will
UNCLASSIFIED27
continue to be reached with index testing and through prevention modalities targeting men at
high risk.
To improve the quality of HIV case finding services for men, the program will continue to support
health facilities to ensure that they are “male friendly” through extended or flexible service hours,
sensitization of health care workers, and other client-centered innovations.
UNCLASSIFIED28
Finding adolescents and young people: Adolescents and young people continue to perform
poorly compared to older people across the clinical cascade. However, using the Zvandiri model,
PEPFAR has significantly improved case identification, linkage and eventually ART coverage
among adolescents and young people. PEPFAR will maintain support for this model and other
client centered adaptations to close the gap in case-finding and linkage to care for harder to reach
adolescents and young people.
Faced with reduced funding for COP 21, the program has found it difficult to sustain the Zvandiri
model budget at COP20 levels although the utility of this model for case finding among children,
adolescents and young people and their subsequent linkage to treatment, care and support is well-
known. Therefore, sustaining epidemic control among the said sub-population will need continued
prioritization, monitoring and focus going forward.
PEPFAR will continue to support and strengthen support groups and other peer-led strategies to
encourage timely ART initiation and retention in care for adolescents and young people. Clinical
partners will continue to strengthen communication and bi-directional referral networks with
community based OVC partners to improve linkage among OVC to critical programs. PEPFAR
will also continue to prioritize case finding and linkage to care among young mothers through
strengthening young mother support groups and linkage to community-based services (e.g., OVC,
DREAMS).
Finding children: Index testing continues to be the main modality for finding children and this
will be supported by the program in COP 21. HIV case finding among children will be
strengthened in COP21 through the epidemic control and concentrated target population model
that incorporates diagnostic testing, as well as collaboration with the OVC program for more
targeted pediatric case finding. Our current aim in COP20 is to achieve full testing coverage for all
biological children of adults in care. Our IPs will intensify index testing among children so that
the case finding recovers to pre-COVID-19 levels.
UNCLASSIFIED29
PEPFAR will continue to support EID POC commodities for mPIMA devices, initially procured
under the UNITAID pilot in Zimbabwe. Through the POCs, EID TAT including result
transmission to caregiver was within 7 days in 92% of the cases and this facilitated the early
initiation of life-saving ART in HIV Exposed Infants (HEI) found to be HIV positive. PEPFAR
partners will support the decentralization of conventional EID platforms and the Integrated
Specimen Transport system while strengthening the delivery of EID results to reduce the turn-
around time.
The PEPFAR program will support the procurement of EID POC commodities, significantly
reducing results turn-around time and enabling immediate linkage to patients will be followed up
and initiated on ART as soon as possible. Efforts to improve and maintain high EID coverage
(95% linkage to ART) include:
1. Support procurement of EID Point of care testing cartridges.
2. Decentralization of EID conventional testing, including piloting of community-based DBS
for children who haven’t been brought to the facility.
3. Integrated sample transportation and expedite electronic result transmission.
4. Expand use of EHR and diary system.
5. Expedite result transmission through electronic means.
6. Continue HIV test and start.
7. Community ART initiation.
8. Cohort monitoring.
9. Use optimized regimens which are child friendly.
10. Ensuring that all infants enrolled in the OVC Program access EID.
As guided by the MoHCC, PEPFAR will support rollout of differentiated HTS for pediatrics as well
as optimized ART regimens. DTG will be rolled out for children with weight >20kgs. Nevirapine
UNCLASSIFIED30
has been phased out as first line treatment, replaced by LPV/r granules procured with support
from PEPFAR. PEPFAR is coordinating with CHAI to introduce DTG 5mg. Most children will be
gradually transitioned onto DTG as it becomes available. The program will also continue to
support the procurement and distribution of Raltegravir granules for sentinel sites.
Case Based Surveillance with Recency Testing
Zimbabwe will focus on increasing efforts to establish case-based surveillance and strengthen data
use. Detecting recent HIV infections among all newly diagnosed individuals in real-time and
establishing a surveillance system to longitudinally track HIV cases has been designated a high
priority activity that will support the attainment and sustenance of HIV epidemic control. Linking
this activity to case finding modalities will help increase HIV-positive yield, early detection of
potential hot spots and subsequent mitigation to reduce HIV incidence among populations. The
longitudinal patient monitoring aspects of CBS, which is integrated into the EHR, will be
necessary to ensure high-quality HIV programming is retaining people in care and keeping them
virally suppressed such that re-ignition of the epidemic does not occur.
Despite the COVID-19 induced delays, in COP 2021, Zimbabwe will continue rapid geographical
expansion of newly diagnosed and recent infection surveillance from 800 sites (expected to have
been covered by end of COP 20) to full national coverage of 1725 by end of COP 21. To rapidly
target case finding efforts in areas of high HIV transmission, Zimbabwe will expedite
implementation of recent infection surveillance. In COP21 all newly diagnosed persons over 15
years of age in the 44 PEPFAR districts and remaining 19 districts supported by Ministry of Health
and Child Care, will be offered recency testing which will be monitored at national level to inform
geographical areas with high concentrations of new HIV infections.
Zimbabwe will continue to build and expand the electronic systems necessary to longitudinally
monitor sentinel events along the continuum of care for all HIV-infected persons living in
Zimbabwe. PEPFAR funds will be used to expand the MoHCC’s Electronic Health Record (EHR)
to ensure all CBS and sentinel events are captured. PEPFAR-support for EHR will focus on system
development and adaptation to accommodate PEPFAR-related priorities including use of a
unique patient identifier agreed on with communities of PLHIV to ensure human rights are
upheld and incorporation of TB-and Cervical Cancer related modules. PEPFAR support will also
fund a landscape analysis of ICT and transmission infrastructure to inform non-PEPFAR donors of
system needs to expedite EHR expansion.
4.2 Continuity of Treatment and Ensuring Viral Suppression
The MoHCC’s Operations and Service Delivery (OSDM) manual for HIV Care and Treatment in
Zimbabwe gives guidance on increasing retention at all steps of the HIV clinical cascade. PEPFAR
Zimbabwe will continue to support the operationalization of this manual and the roll-out of
differentiated service delivery models. In COP 21, PEPFAR will use the continuity of treatment
framework below to guide support for various interventions that facilitate continuity of treatment
and viral suppression for PLHIV.
UNCLASSIFIED31
PEPFAR Zimbabwe will support interventions that prevent loss or interruption in treatment,
activities that improve tracking and documentation and lastly interventions targeting missed/ lost
clients and special populations as outlined in the figure below.
PEPFAR Zimbabwe also will continue to support the expansion of DSD to increase the proportion
of stable adolescent and adult clients in DSD models for ART to 80% among those eligible by
December 2021. The pie chart details the proposed mix of DSD models which are in line with the
MoHCC’s targets.
UNCLASSIFIED32
CARG
17%
Family Refill
Conventional
6%
Care Outreach
45% 2%
Facility Club
Refill
10%
Fast track
20%
DSD models will focus on the following key objectives:
• DSD to reduce clinic visits: multi-month dispensing, community ART refill groups
(CARGSs, and family refills)
• DSD to shorten clinic visit: fast track refills, scheduled appointment times that reduce
waiting time and congestion.
• DSD to improve patient convenience: family centered care, convenient locations like
community posts and private pharmacies.
PEPFAR will fund and expand differentiated service delivery for ART refills that are convenient
and confidential (e.g., private drug pick-up and refill points). Implementation of differentiated
service delivery for HIV treatment will be scaled to reach at least 60% of all PLHIV and ensure a
minimum 25% are accessing treatment from a community model and at least 20% from a group
model.
Prevention of treatment interruption: Interventions will include completion of transition to TLD
treatment for all eligible clients, early case management, formalized SMS reminders wherever
available and access to individual and peer counselling as needed. Through ongoing dialogue with
the MoHCC, the PEPFAR program will support the orientation of facility staff on respectful
management of clients including being friendly and non-judgmental. In COP21 the PEPFAR
program will support various aspects of Advanced HIV Disease (AHD) management including
adaptation of new WHO AHD guidelines, TB Urine-Lam, and Serum CrAG. PEPFAR will leverage
medicines for opportunistic infections which will be procured under the GF. The PEPFAR
program will also support the adaptation of the latest WHO guidelines particularly regarding
timing of ART in patients with active TB disease to prevent loss through death. The
implementation and scale up of 6 MMD and other differentiated services will continue to be a
priority. For adolescents, the Zvandiri (CATS) model approach will continue with a focus those
with the highest HIV burden among this age group.
The OVC Program currently is case managing about 67% of C/ALHIV in 21 Districts and through
various activities, will continue to ensure that they are retained in care as well as monitoring and
ensuring that they are virally suppressed.
Improved tracking and documentation: In COP 21, EHR is expected to have saturated PEPFAR DSD
districts, and this is expected to be a game-changer with regards to client documentation. Use of
EHR will facilitate systematic early missed appointment tracking, interruption in treatment, gaps
UNCLASSIFIED33
in services provided to an individual client among other functions. The PEPFAR program will
engage some of the existing lay cadres to become retention facilitators who will take on the role of
intensive defaulter tracking that will begin within 24 hours of clients having missed
appointments. These cadres will work with the clinicians to ensure clients return to care and
follow up outcomes are documented appropriately in the client files. Cadres conducting support
will be provided to clinicians to separate the files of clients who have missed appointments from
those who have defaulted and those who are lost to follow up.
Special populations: The PEPFAR program will continue to engage the MoHCC to develop
enhanced differentiated service delivery models tailored to suit each individual population group.
Particular attention will be paid to clients who are unstable and/or have advanced disease.
Additional emphasis will be on having mental health services/substance abuse screening
introduced and scaled up. The feasibility of standardizing and formalizing the cross border DSD
model will continue to be explored.
Community Led Monitoring: PEPFAR will support community led organizations to visit PEPFAR
funded sites to evaluate the quality of services offered to communities including people living
with HIV, young people, key populations. The organizations will be supported to visit sites across
the country throughout the year and reports on quality of service will be shared to improve
service delivery.
UNCLASSIFIED34
Treatment Literacy: In COP 2021, PEPFAR will ensure ongoing activities to improve treatment
literacy among PLHIV and ensure that appropriate messages are delivered in appropriate ways to
the various population subgroups. These messages will include the rationale for the Treat All
approach, the benefits of testing and initiating ART prior to onset of symptoms, the superior
efficacy and adverse event profile of dolutegravir (DTG)-based regimens, the importance of
having all sexual partners on treatment or PrEP, the need for viral load monitoring and the
meaning of viral load results, U=U (Undetectable = Untransmittable), and so on. Once the VL
literacy package “Flip the Script” is completed, the PEPFAR program will explore the use of this
communication package to improve clients’ understanding of adhering to treatment and VL
results interpretation. PEPFAR will continue to support the updating of counseling materials and
guidelines to align with the current treatment recommendations and the shifts in the HIV
program.
UNCLASSIFIED35
During COP 2019, PEPFAR Zimbabwe supported the development, printing, and dissemination of
a “Comprehensive National HIV Communications Strategy for Zimbabwe – 2019-2025”. This
document will be the basis for continued revitalization of widespread treatment literacy amongst
ART patients. Working with civil society groups and their constituents, treatment literacy
messages tailored to specific population groups in specific areas will be guided by the strategy.
Given the inadequate knowledge on issues such as index testing, TLD transition, viral load etc.,
widespread dissemination of these messages will be a priority. These efforts will be continued for
the remainder of COP 2020 implementation and into COP 2021.
Quality Improvement: The national HIV Quality Improvement strategy establishes indicators and
guidelines for measuring the quality-of-service delivery and improving performance towards
those indicators. Importantly, this strategy considers client feedback to promote client-centered
care. PEPFAR support towards the national HIV Quality Improvement program takes the form of
secondees who provide technical guidance, ensuring that this program is aligned with PEPFAR
and UNAIDS strategy for achieving HIV epidemic control. Through this support, facilities
implemented QI initiatives resulting in improved patient care and this will continue during
COP21 to focus on improving VL and TPT uptake. At the site-level, systems-level interventions to
improve monitoring of patient satisfaction, linkage rates, same day initiation and improved M&E
for PEPFAR treatment indicators, will be streamlined into the site-level support provided by the
clinical partners.
Ensuring viral load suppression: PEPFAR has identified viral load (VL) access and suppression as a
critical area needing intervention in Zimbabwe as the country reaches epidemic control. Besides
the obvious VL reagent gap, there are still gaps in access, specimen transport and results
utilization/ clinical status monitoring. FY20 Q4 PEPFAR data from the indicates an observed
lower VLC in young adults and children below 14 years as shown in the figure below.
The program has also noted that the utilization of viral load results is sub-optimal pointing to the
need to strengthen the capacity of clinicians. In COP 21, PEPFAR will therefore continue to invest
in scaling up CLI in all supported districts, ensuring that the clinical partners, OVC/ community
partners, and the laboratory partner work harmoniously and measurably to increase access to VL
UNCLASSIFIED36
services for all eligible PLHIV already on ART. The goal of the strategy is 90% coverage by the end
of FY 21, which exceeds the Community COP request for 85% coverage.
Scaling up TPT: Globally, TB continues to the leading infectious disease killer, yet it is a
preventable and curable disease. The available prevention interventions, like TB preventive
treatment (TPT), have not been taken to scale for various reasons. During COP19 (FY20)
implementation, 120,939 PLHIV completed TPT in PEPFAR supported districts, with completion
rate of 83.9%. This is a significant increase from 39,541 that completed TPT in COP18 (FY19). In
COP21 we will continue to scale up TPT to achieve universal coverage over the next two financial
years. However, there are challenges that our program is committed to overcome to achieve
universal TPT coverage. In 2014, a study conducted in Zimbabwe revealed that only half of
patients received IPT due to inadequate advocacy, community sensitization, formally trained
staff, education, and communication materials, and IPT stocks. These challenges are still present
today and planning for and addressing each of these components will be critical for successful
TPT scale up.
In consultation with the MoHCC, and in line with the existing capacity within the health care
system, TPT targets were agreed as 275,842 for COP 21.
TPT Completions
80,000 88.2% 83.9% 83.9% 100.0%
70,000 66,922 90.0%
80.0%
60,000 72.7% 54,017
70.0%
50,000 76.7%
60.0%
40,000 50.0%
46.2%
30,000 40.0%
21,695
17,826 30.0%
20,000
20.0%
10,000 10.0%
33 144 134
0 3.1% 0.0%
2017 Q4 2018 Q2 2018 Q4 2019 Q2 2019 Q4 2020 Q2 2020 Q4
No. of TPT completions Proportion completing
In COP 21, the PEPFAR program will continue to support the procurement and distribution of
TPT medicines and complement the Global Fund’s support. Implementation of the shorter TPT
regimens, 3HP (three months rifapentine and isoniazid) and 3HR (3 months isoniazid and
rifampicin) will be fully brought to scale in COP21 such that an estimated 69% of patients will be
on 3HP. The rollout of 3HP started in COP20 in 18 health facilities through a Clinton Health
Access Initiative (CHAI) catalytic mechanism. The first delivery of 3HP fixed dose combination
(FDC) tablets was received and distributed during COP20 Q2. 3HP reduces high pill burden and
improves adherence, as a once weekly regimen taken only for 3 months.
As guided by PEPFAR and MoHCC guidelines the following groups will be prioritized in TPT scale
up:
UNCLASSIFIED37
- PLHIV on DTG based ART regimens 6H plus Vitamin B6 (FDC - INH/CTX/Vitamin B6)
- PLHIV on EFV based ART regimens : 3HP
- HIV negative children and adolescents 95% screening target. Presumptive TB rate among new and existing
patients on ART was 4.8% and 0.9% respectively. During COP20 and continuing in COP21 the
program is systematically working to increase screening coverage and quality. Health facilities
with support from PEPFAR IPs are rolling out quality improvement and assurance projects to
improve screening. Sensitization and mentoring on TB screening has been scaled up. TB
screening with urine lipoarabinomannan (urine-LAM) was introduced to complement the existing
strategies. In COP21 urine-LAM will be introduced in all PEPFAR supported districts to improve
TB screening and diagnosis. PEPFAR funds will be used to procure urine-LAM kits, develop
appropriate SOPs and job aides, and support training and mentoring of health workers.
4.3 Prevention, specifically detailing programs for priority programming:
HIV prevention for priority populations remains a key strategy in COP 21, with prevention
activities tailored to specific populations being delivered through the VMMC, DREAMS, Key
Populations (KP) and OVC platforms, as well as through HTS, PMTCT and ART services. Targeted
priority populations include adolescent girls and young women (AGYW) between 15-24 years old,
children (through prevention of vertical HIV transmission), sex workers, men who have sex with
men, transgender women, and men under the age of 30, with a focus of linking this group to HTS
and VMMC. PEPFAR will continue to focus on primary prevention of sexual violence and HIV for
adolescent boys and girls 9-14 years old through the OVC and DREAMS initiatives.
UNCLASSIFIED38
As part of the COP20 development process, on which COP21 will build, PEPFAR conducted a
detailed, data-driven analysis of availability, access, and sources of funding for condoms to
determine specific needs for commodities and to assess the feasibility of transitioning aspects of
the condom program to Government ownership. Zimbabwe has made significant strides in using
a Total Market Approach for condom programming, with strong leadership by the MoHCC
through high level advocacy efforts to improve market conditions for the commercial sector and
advocacy to increase domestic financing for condoms.
Despite those efforts, the share of commercial sector share to the condom market is shrunk
(resulting from high inflation, reducing purchasing power of buyers) and there has been no
commitment by Government to prioritize scare Forex to procure condoms going forward. Public
sector condom distribution (currently funded 100% through PEPFAR) retains the largest share of
the market, although volumes declined from FY19 to FY20 due to temporary instability in the
supply chain system (e.g., delivery of condoms to service points, closed outlets) because of
COVID-19.
While there has been substantial progress to achieve cost recovery of the Protector Plus Social
Marketing program, with higher revenues and a more efficient sales/distribution strategy
resulting in 100% of operating costs recovered by the end of 2018, Zimbabwe is still not ready to
graduate the social marketing program. PEPFAR still needs to donate commodities and
packaging.
Initially, the collapse of the “Zim Dollar” and high rates of inflation made sustained cost recovery
extremely difficult. Recently, the impact of COVID-19 and high cost of living within the harsh
economic environment has led to low sales even in the dollarized economy.
UNCLASSIFIED39
In COP 21, PEPFAR will leverage innovations to sustain CSM through reducing operating costs,
exploring distribution partnerships with commercial sector players, establishing a merchandising
service partnership with a commercial sector player, strengthening customer engagement
through digital platforms, and establishing and branding youth friendly outlets.
UNCLASSIFIED40
In COP21 PEPFAR will contribute $3,800,000 to condom programming and continue to
coordinate with the Global Fund on their new commitments, increase its COP contribution by
186% to decrease reliance on the Central Commodity Fund, while continuing to support the most
critical elements of the national condom program. PEPFAR will continue to source male and
female condoms and personal lubricants for distribution through public sector and program
service delivery points, as well as for sale through the Protector Plus social marketing program
(male condoms only). While PEPFAR will provide the commodities and packaging, the condom
social marketing program will partially graduate, funding 100% of its operating costs through sales
revenues, while maintaining affordable pricing to drive volumes, maintain shelf space and
promote commercial sector re-entry. PEPFAR will continue to integrate condom education and
distribution in and around all clinical touchpoints and strengthen targeted community-based
distribution for high-risk men, KP and AGYW. Finally, PEPFAR will continue to work closely with
the MoHCC and the National Condom TWG to address regulatory impediments to market
growth, ownership, stewardship, and sustainability of the condom program, including domestic
sources, beyond COP 20.
a. Pre-exposure Prophylaxis (PrEP) for Priority Populations
To date PEPFAR support for PrEP rollout has concentrated on AGYW (as part of DREAMS), FSW
and MSM (as part of the KP program). The program initiated a total of 13,004 individuals on PrEP,
reaching 158% of the FY 20 target despite the COVID-19 lockdown restrictions. Uptake continued
to be strong among MSM, FSW, AGYW and other high-risk women, with Harare contributing the
largest proportion of new on PrEP.
UNCLASSIFIED41
The strong performance is attributed to COVID-19 adaptations such as virtual demand creation
and appointment bookings, community refills, the DREAMS Sexual Referral Network (SRN)
model and the models that were in place prior to COVID-19: ColourZ for MSM, scale up of
differentiated PrEP delivery using drop-in centers managed by GALZ, SRC and HoH, visiting
homes of sex worker queens to initiate and re-supply PrEP and the use of DREAMS Ambassadors
that were leveraged to increase access to PrEP services for other high risk women. The scale up
and expansion of the DREAMS Ambassador model to YW 20-24 in COP20 also contributed to
increased uptake among AGYW 15-24.
Despite improved uptake of PrEP among priority populations, continuation remains a challenge,
with most discontinuation occurring in the first 4 months. Commonly cited reasons for PrEP
UNCLASSIFIED42
discontinuation were self-reported change in risk level, poor tolerance of side effects, and COVID-
19 induced relocation to areas where PrEP is unavailable.
In COP21 PEPFAR will expand PrEP for priority populations delivering PrEP to 50,117 clients and
increasing the number of new initiations by 70% in COP 21. PEPFAR will continue to expand
coverage among KP and AGYW, capitalizing on the increased geographic footprint of DREAMS,
and support service delivery for SDCs, TG, and pregnant and breastfeeding women.
The COP 2021 strategy for PrEP is summarized as follows:
• Strengthening PrEP integration across clinical entry points (ANC, OI/ART, STI and FP)
and community platforms (DREAMS, KP)
• Ensure providers are trained in LIVES to prevent and provide comprehensive and timely
response to any cases of violence.
• Support public sector roll out of PrEP in selected health facilities by reviewing patient flow
and risk screening processes for different entry points;
• Strengthening M&E of the PrEP program, data capture and use, documentation, and
program improvement
• Supporting clinical mentoring and patient navigation where needed.
• Communication efforts to increase demand and ‘normalize’ PrEP.
• Improve PrEP literacy for PrEP users.
• Offer a mix of client-centered approaches to enable service delivery and improve
continuation, including PrEP delivery through KP Drop-in Centers and mobile SW clinics,
mobile PrEP refills integrated with community SRH, index testing, defaulter tracking, ART
refills and VL sample collection.
• All newly diagnosed HIV infected PrEP clients (especially KPs, AGYW and PBFW) will be
screened for gender-based violence at ART initiation and supported.
• The program will continue to offer PEP to all those with a recent exposure with potential
for HIV transmission, with those completing PEP and testing negative linked to PrEP and
relevant prevention intervention e.g., DREAMS for AGYW, OVC sexual violence
prevention interventions for 9–14-year-old boys and girls, KP programming for KPs etc.
• Leverage centrally funded microbicide technical assistance through centrally funded
USAID microbicide program and support a demonstration project of the Dapivirine Ring.
Please note that the details of this demonstration project are still under consideration at
the time of the SDS submission. Discussions will be held with civil society as the project
unfolds.
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